Wednesday, January 31, 2018

The article talks
about unannounced JC visits. True, they are unannounced, but not
unexpected. Hospital administrators seem to be able to predict their
arrival with a margin of error of a few days and prepare months in
advance. More than anything else it is probably the heightened
vigilance around the visits that is of benefit.

Sunday, January 28, 2018

A woman in her 20s
with ulcerative colitis presented with acute-onset left-sided
pleuritic chest pain for 3 days. She had a medical history of
unprovoked deep vein thromboses (DVT) and pulmonary embolism (PE) and
had been taking coumadin without any issues. Ten years before, she
had had a retrievable inferior vena cava filter (RIVCF) placed for
intraoperative PE prophylaxis for total colectomy for ulcerative
colitis. She denied being off anticoagulation medication ever or any
medical history of bleeding or new thromboses while on warfarin, or
during the perioperative period. The RIVCF was never removed. A
computed tomographic (CT) angiography ruled out any new PE, but
showed IVCF fragments in the pulmonary vasculature. Two of the 3
pieces (Figure, A) and the RIVCF (Figure, B) were removed and her
pain improved. The third piece was irretrievable owing to location
deep in the pulmonary vasculature. She continued to have intermittent
chest pain over the next 6 months and CT showed another IVCF fragment
in right atrial musculature (Figure, C) which was obscured by
contrast on prior CT angiograms. The risks involved with open-heart
surgery for retrieval of this fragment were discussed with the
patient and she decided against any intervention. Her chest pain
resolved spontaneously over the next 2 months. She continues to take
coumadin without any issues.

To top it off it was
done for a weak indication and could have been removed early.

Saturday, January 27, 2018

Objective:
Angiotensin II is an endogenous hormone with vasopressor and
endocrine activities. This is a systematic review of the safety of IV
angiotensin II.

Data Sources:
PubMed, Medline, Scopus, and Cochrane.

Study Selection:
Studies in which human subjects received IV angiotensin II were
selected whether or not safety was discussed.

Data Extraction: In
total, 18,468 studies were screened by two reviewers and one arbiter.
One thousand one hundred twenty-four studies, in which 31,281
participants received angiotensin II (0.5–3,780 ng/kg/min), were
selected. Data recorded included number of subjects, comorbidities,
angiotensin II dose and duration, pressor effects, other physiologic
and side effects, and adverse events.

Data Synthesis: The
most common nonpressor effects included changes in plasma
aldosterone, renal function, cardiac variables, and electrolytes.
Adverse events were infrequent and included headache, chest pressure,
and orthostatic symptoms. The most serious side effects were
exacerbation of left ventricular failure in patients with congestive
heart failure and bronchoconstriction. One patient with congestive
heart failure died from refractory left ventricular failure.
Refractory hypotensive shock was fatal in 55 of 115 patients treated
with angiotensin II in case studies, cohort studies, and one
placebo-controlled study. One healthy subject died after a pressor
dose of angiotensin II was infused continuously for 6 days. No other
serious adverse events attributable to angiotensin II were reported.
Heterogeneity in study design prevented meta-analysis.

Conclusion: Adverse
events associated with angiotensin II were infrequent; however,
exacerbation of asthma and congestive heart failure and one fatal
cerebral hemorrhage were reported. This systematic review supports
the notion that angiotensin II has an acceptable safety profile for
use in humans.

Despite the
relationship between idiopathic pulmonary fibrosis (IPF) and
advancing age, little is known about the epidemiology of interstitial
lung disease (ILD) in the elderly. We describe the diagnoses,
clinical characteristics, and outcomes of patients who were elderly
at the time of ILD diagnosis.

Methods

Among subjects from
a prospective cohort study of ILD, elderly was defined as age ≥ 70
years. Diagnoses were derived from a multidisciplinary review.
Differences between elderly and nonelderly groups were determined
using the χ2 test and analysis of variance.

Results

Of the 327 subjects
enrolled, 80 (24%) were elderly. The majority of elderly subjects
were white men. The most common diagnoses were unclassifiable ILD
(45%), IPF (34%), connective tissue disease (CTD)-ILD (11%), and
hypersensitivity pneumonitis (8%). Most elderly subjects (74%) with
unclassifiable ILD had an imaging pattern inconsistent with usual
interstitial pneumonia (UIP). There were no significant differences
in pulmonary function or 3-year mortality between nonelderly and
elderly subjects combined or in a subgroup analysis of those with
IPF.

Conclusions

Although IPF was the
single most common diagnosis, the majority of elderly subjects had
non-IPF ILD. Our findings highlight the need for every patient with
new-onset ILD, regardless of age, to be surveyed for exposures and
findings of CTD. Unclassifiable ILD was common among the elderly, but
for most, the radiographic pattern was inconsistent with UIP.
Although the effect of ILD may be more pronounced in the elderly due
to reduced global functionality, ILD was not more severe or
aggressive in this group.

U.S. adults
recruited from Research Now, an online panel of individuals
compensated for performing academic and marketing research surveys.

Interventions

In the control
version of the vignettes, the physician’s rationale for
recommending against the service was the minimal benefit and
potential for harm. In the altruism version, the rationale
additionally included potential benefit to others by forgoing that
service.

Main Measures

Differences in
requests for overused services and physician ratings between
participants randomized to the control and altruism versions of the
vignettes.

Key Results

A total of 1001
participants were included in the final analyses. There were no
significant differences in requests for overused services for any of
the clinical scenarios (P values ranged from 0.183 to 0.547).
Physician ratings were lower in the altruism version for the acute
sinusitis (6.68 vs. 7.03, P = 0.012) and back pain scenarios
(6.14 vs. 6.83, P less than 0.001), and marginally lower for the
healthy adult scenario (5.27 vs. 5.57, P = 0.084).

Conclusions

In this experimental
survey, altruistic appeals delivered by physicians did not reduce
requests for overused services, and resulted in more negative
physician ratings. Further studies are warranted to determine whether
alternative methods of appealing to patient altruism can reduce
overuse.

Though this study is
not very “real world” it makes sense, especially the finding of
lower physician ratings.

An argument against
low value care based on ineffectiveness is fine and patients ought to
be able to respect it. But an appeal to altruism sends a message
that you can’t whole heartedly advocate for them as individuals.
Imagine you are accused of a crime and your attorney says “I’ll
work hard to represent you but please keep in mind the interests of
‘the people’ in these proceedings.”

As part of the
Choosing Wisely® campaign, the Society of Hospital Medicine
recommends against performing “repetitive complete blood count
chemistry testing in the face of clinical and lab stability.” With
this recommendation as a framework, we targeted 2 hospitalist-run
inpatient medicine units that employed bedside, scripted,
interdisciplinary rounds. Our multifaceted intervention included
prompting the hospitalist to identify clinically stable patients for
next-day discharge and to discontinue labs when appropriate. It was
coupled with the education of the clinicians and a regular data
review for the hospitalists and unit staff. Among 2877 discharges
included in a 1-year period, there was a significantly decreasing
trend after the intervention in the percentage of patients getting
labs in the 24, 48, and 72 hours before discharge (−1.87%, −1.47%,
and −0.74% decrease per month, respectively; P less than 0.05). Our
structured, multifaceted approach effectively reduced daily lab
testing in the 24 to 48 hours prior to discharge.

Though statistically
significant the magnitude of success was not what I would call
robust.

All patients with active peptic ulcer disease (PUD), a past history
of PUD (unless previous cure of H. pylori infection has been
documented), low-grade gastric mucosa-associated lymphoid tissue
(MALT) lymphoma, or a history of endoscopic resection of early
gastric cancer (EGC) should be tested for H. pylori infection…

The guideline makes these additional statements regarding patients
who should be considered for testing (softer recommendation):

In patients with uninvestigated dyspepsia who are under the age of 60
years and without alarm features, non-endoscopic testing for H.
pylori infection is a consideration…

In patients taking long-term low-dose aspirin, testing for H. pylori
infection could be considered to reduce the risk of ulcer bleeding…

Adults with idiopathic thrombocytopenic purpura (ITP) should be
tested for H. pylori infection. Those who test positive should be
offered eradication therapy (conditional recommendation, very low
quality of evidence).

How should
testing be carried out?

If an EGD is not being done, from the review:

Helicobacter pylori infection can be diagnosed using noninvasive and
invasive methods. In general, both noninvasive and invasive tests are
equally accurate.13 Noninvasive tests include the urea breath test,
fecal antigen test, and serologic test. The preferred noninvasive
tests in the outpatient setting are the urea breath test and fecal
antigen test given their excellent accuracy and ability to diagnose
active infection. The fecal antigen test relies on identifying H
pylori antigens in the stool using an enzymatic immunoassay.13 In the
urea breath test, urea labeled with 13C or 14C is given to patients.
Urease, if present, converts urea into ammonia and labeled CO2 that
is exhaled, indicating a positive result.13 Before testing, proton
pump inhibitors (PPIs) and antibiotics should be discontinued at
least 2 and 4 weeks, respectively, as these can interfere with the
urea test.10 Pretreatment sensitivity and specificity of both these
tests are approximately 95%.13 Although the cost of testing varies by
location and laboratory, the estimated cost of the urea breath test
and fecal antigen test is $102.80 and $19.70, respectively.14
Serologic testing is not recommended to detect active infection, as
it cannot distinguish between active disease and previous exposure.
Antibodies to H pylori can remain elevated for a long time even after
treatment, potentially increasing the number of false-positive
results.13 The 1 positive aspect of serologic testing is that it is
the only test for H pylori that is not affected by PPI therapy,
antibiotics, or by the presence of blood in the stomach.

If EDG done, again from the review:

Invasive testing strategies require upper endoscopy and include the
biopsy urease (campylobacter-like organism) test, histologic
assessment, and culture. The biopsy urease test is a good first-line
test, as it is accurate, rapid, and inexpensive. This test relies on
H pylori urease to convert urea into ammonia, increase the pH, and
change the color of the pH indicator.15 Although the specificity is
excellent with this test (greater than 95%), the sensitivity can vary
from 75% to 98%.15 The urease test is preferred in patients without
recent use of PPIs and antibiotics, as outlined above.10 However, in
patients with recent PPI or antibiotic use, histologic assessment of
biopsy samples is the better choice, although these medications can
interfere with bacterial density.

It is currently believed that an acquired form of HCM, including
“IHSS physiology”, can be seen in the elderly, arising from LVH
secondary to hypertension or valvular aortic stenosis. The exception
is that these patients generally don’t have asymmetric septal
hypertrophy (ASH) but rather concentric LVH.

What about the
genetics?

A genetic abnormality can be found in most younger patients with HCM
and a positive family history.

Up to Date says many mutations have been found in 11 genes.

According to the ACC/AHA guidelines genetic screening has a
class IIa recommendation for an index case. Screening of first
degree relatives can be clinical (phenotypic) or genetic. Genetic
screening to assess the risk of SCD carries only a IIb
recommendation. Cost considerations apply in the real world.

What are the
anatomic and physiologic variants?

HCM does not always present with the classic “IHSS” phenotype.
From my reading of Up to Date, other variants include DUST (which may
occur in isolation and not represent HCM, see above), mid septum and
free wall hypertrophy resulting in an intracavitay gradient, free
wall greater then septal hypertrophy (rare), varying degrees of
concentric LVH, and apical HCM (Yamaguchi syndrome).

What are the risk
factors for SCD and how should they be taken into account in deciding
whether to recommend an AICD?

From the Circulation article:

Accepted risk factors for SCD are unexplained syncope; family history
of SCD due to HCM or occurring with no other explanation before 50
years of age; extreme (greater than 30 mm) LVH; ventricular
tachycardia, as detected by Holter monitoring; and an abnormal blood
pressure response to exercise. Young and middle-aged patients at risk
of SCD are usually offered an implantable cardioverter-defibrillator.
The risk of SCD may be lower in elderly patients with HCM, but there
is uncertainty with regard to how to adapt the conventional risk
factors to this population.

These factors are taken together, and a clinical scoring tool is
available. Genetic testing to decide on device implantation is not
highly recommended.

What are the
medical treatments? Where do surgical treatments and septal ablation
fit in?

Monday, January 22, 2018

There’s an
interesting article in the Journal of Hospital Medicine on
what to do when a patient wants to leave the hospital against medical
advice. After reading and rereading it I had to disagree with the
conclusion but it took me a bit to get there because the article,
with its confusing use of terms, is a masterpiece of obfuscation.
The most obvious example is the oxymoronic use of the term “AMA
discharge” in the title and throughout the article. If a patient
leaves AMA it's not your decision. How is that a discharge? Put
another way, if you discharge the patient you are making a statement
that the patient is medically ready to leave the hospital. A
discharge order can only mean the patient is leaving in accordance
with, not against, your advice. Why, after all, would you enter an
order for something that is against your own judgment?

Another example of
language confusion is the authors’ statement that leaving the
hospital AMA can be a process of informed consent. Quoting directly
from the article:

Because all
competent patients have the right to decline recommended inpatient
treatment, the ethical and legal standard is that the physician
obtain the patient’s informed consent to leave…

Consent to leave?
That’s an inappropriate use of the word. Consent leads to adherence with
the physician’s recommendation, which in this case would be to
remain in the hospital. In the AMA situation the patient’s
decision to leave is a demand, not a consent.

Getting past all the
confusion, there were a few good points. When the patient leaves
against your advice you don’t have to destroy the rapport. It
doesn’t have to be an adversarial transaction. But the authors go
beyond that principle by stating that when the patient leaves AMA not
only should it be handled as a regular discharge but that you should
not even document that the departure is against your advice. Again,
form the article:

The solution to
improve quality is straightforward—avoid designating discharges as
AMA…

There's more to
unpack. The authors make frequent mention of shared decision-making.
Indeed shared decision-making is a is a core principle of
evidence-based medicine but it is just one component. The AMA
departure sometimes pushes shared decision making to the level of
absurdity. How does it apply, for example, if the patient with an
actively evolving myocardial infarction wants to leave the emergency
room? What if the patient just swallowed antifreeze because he ran
out of his beverage of choice? Where does shared decision making
come in when the patient’s choice means almost certain harm? Some
patient preferences and choices are simply wrong.

Finally there's the
matter of legal protection. The authors make this statement:

Although clinicians
may presume that the AMA designation provides protection from
liability, the claim is not supported by the available
literature.14,15 In these studies, which reviewed relevant case law,
defendants prevailed not because of the physician’s AMA
designation, but because the plaintiff was not able to prove
negligence.

That’s a
misrepresentation of the cited articles. Both articles (see here
and here) contain
statements to the effect that the AMA designation may indeed afford
some legal
protection.

So what should we
do? Why not consider each case on its individual merits? If the
patient wants to leave prematurely but the risk is low it may be
reasonable to capitulate and enter a discharge order. In other
situations where the patient's choice is clearly ill-advised and the
risk is high a discharge order may be inappropriate and the departure
should be documented as being against medical advice. Even in such
cases try to work with the patient to help formulate a follow-up plan
and, if appropriate, provide medication prescriptions. Assure the
patient that you are not angry, respectfully ask that they reconsider
and assure them that they are welcome to return. Clearly advise them
about the danger of leaving but don’t threaten them or imply
adverse insurance consequences.

Recommendations are
that all patients with cirrhosis be screened as well as certain
hepatitis B patients regardless of cirrhosis if certain risk factors
are present. Some guidelines make similar recommendations for
hepatitis C. The screening modality of choice is ultrasound.
Imaging is favored over tumor markers.

Sunday, January 21, 2018

Below are some key
points from a couple of free full text reviews [1] [2].

Terminology has
changed and can be confusing

The current official term is calcium pyrophosphate crystal deposition
(CPPD). Pseudogout, a term which historically referred to the acute
attacks of CPPD, has been replaced by “acute calcium pyrophosphate
crystal arthritis.” The plain radiographic finding known as
chondrocalcinosis is frequently replaced by the term “cartridge
calcification.” CC is not universal in patients with attacks nor
is it entirely specific for CPPD.

Crystal
identification is important in diagnosis

As opposed to the needle like negatively birefringent crystals of
gout, the crystals of CPPD are variable in shape, often rectangular,
and if birefringent at all, only weakly positively birefringent.

Metabolic disease associations of CPPD include
haemochromatosis (18), hyperparathyroidism (19, 20),
hypomagnesemia (21) and hypophosphatasia (22). Other diseases
such as diabetes mellitus and hypothyroidism do not associate
with CPPD once adjusted for age (22, 23). Haemochromatosis
is the only metabolic disease associated with CPPD that
results in structural arthropathy, and this commonly affects
the knees, wrists, hips, MCPJs, and ankles (18, 24).

Saturday, January 20, 2018

Evidence-based and
expert-based guidelines emphasize the need for adequate nutritional
intake to improve nutritional status. For infants and young children,
the aim is to achieve the 50th percentile of weight and length for a
healthy same-age population up to age 2 years. For older children and
adolescents 2–18 years, the target is a BMI of at or above the 50th
percentile for healthy children. For CF adults of at least 18 years,
the target is a BMI of at or above 22 kg/m 2 for women and at or
above 23 kg/m 2 for men. Recently, new drugs are developed with the
aim to treat the malfunction of the cystic fibrosis transmembrane
conductance regulator gene. This potentiator/corrector therapy
improves lung function and nutritional status and decreases the
number of infective exacerbations. As survival is improving and the
CF population is aging, it is important to focus on micronutrient and
macronutrient intake of CF patients in different age and disease
stages.

Summary

Recent
evidence-based nutritional guidelines and improved medical treatment
support the nutritional monitoring and interventions in CF patients.
Nutritional care should be personalized and provided by a specialized
CF dietitian because patients’ care needs may change dramatically
during their disease progress.

Friday, January 19, 2018

Insomnia is the most
prevalent sleep disorder in the United States and has high
comorbidity with a number of cardiovascular diseases (CVDs). In the
past decade, a number of observational studies have demonstrated an
association between insomnia and incident cardiovascular disease
(CVD) morbidity and mortality, including hypertension (HTN), coronary
heart disease (CHD), and heart failure (HF). Despite some
inconsistencies in the literature, likely due to variations in how
insomnia is defined and measured, the existing data suggest that
insomnia, especially when accompanied by short sleep duration, is
associated with increased risk for HTN, CHD and recurrent acute
coronary syndrome, and HF. Purported mechanisms likely relate to
dysregulation of the hypothalamic-pituitary axis, increased
sympathetic nervous system activity, and increased inflammation. This
paper reviews the most recent studies of insomnia and CVD and the
potential pathophysiological mechanisms underlying this relationship
and highlights the need for randomized trials to further elucidate
the nature of the relationship between insomnia and CVD.

Thursday, January 18, 2018

There is no
significant evidence of long term efficacy of insulin on any clinical
outcome in T2D. However, there is a trend to clinically harmful
adverse effects such as hypoglycaemia and weight gain. The only
benefit could be limited to reducing short term hyperglycemia. This
needs to be confirmed with further studies.

Design:
Double-blind, randomized clinical trial (ClinicalTrials.gov:
NCT01783821). The primary outcome was longitudinal change in oxygen
saturation divided by the FIO2 (S/F) through day 5. We also analyzed
categorical change in S/F by greater than 20%. Other outcomes
included need for mechanical ventilation and development of acute
respiratory distress syndrome.

Measurements and
Main Results: Sixty-one patients were enrolled from September 3,
2013, to June 9, 2015. Median time from presentation to first study
drug was less than 9 hours. More patients in the control group had
shock at enrollment (14 vs 3 patients). The longitudinal increase in
S/F was greater in the treatment group (p = 0.02) and independent of
shock (p = 0.04). Categorical change in S/F improved (p = 0.01) but
not after adjustment for shock (p = 0.15). More patients in the
placebo group developed acute respiratory distress syndrome (7 vs 0)
and required mechanical ventilation (53% vs 21%).

Conclusions: Early
treatment with inhaled budesonide/formoterol in patients at risk for
acute respiratory distress syndrome is feasible and improved
oxygenation as assessed by S/F. These results support further study
to test the efficacy of inhaled corticosteroids and beta agonists for
prevention of acute respiratory distress syndrome.

Tuesday, January 16, 2018

Background Findings
from recent studies show that microvascular injury consists of
microvascular destruction and intramyocardial hemorrhage (IMH).
Patients with ST‐segment elevation myocardial infarction (STEMI)
with IMH show poorer prognoses than patients without IMH. Knowledge
on predictors for the occurrence of IMH after STEMI is lacking. The
current study aimed to investigate the prevalence and extent of IMH
in patients with STEMI and its relation with periprocedural and
clinical variables.

Methods and Results
A multicenter observational cohort study was performed in patients
with successfully reperfused STEMI with cardiovascular magnetic
resonance examination 5.5±1.8 days after percutaneous coronary
intervention. Microvascular injury was visualized using late
gadolinium enhancement and T2‐weighted cardiovascular magnetic
resonance imaging for microvascular obstruction and IMH,
respectively. The median was used as the cutoff value to divide the
study population with presence of IMH into mild or extensive IMH.
Clinical and periprocedural parameters were studied in relation to
occurrence of IMH and extensive IMH, respectively. Of the 410
patients, 54% had IMH. The presence of IMH was independently
associated with anterior infarction (odds ratio, 2.96; 95% CI,
1.73–5.06 [P less than 0.001]) and periprocedural glycoprotein
IIb/IIIa inhibitor treatment (odds ratio, 2.67; 95% CI, 1.49–4.80
[P less than 0.001]). Extensive IMH was independently associated with
anterior infarction (odds ratio, 3.76; 95% CI, 1.91–7.43 [P less
than 0.001]). Presence and extent of IMH was associated with larger
infarct size, greater extent of microvascular obstruction, larger
left ventricular dimensions, and lower left ventricular ejection
fraction (all P less than 0.001).

Conclusions
Occurrence of IMH was associated with anterior infarction and
glycoprotein IIb/IIIa inhibitor treatment. Extensive IMH was
associated with anterior infarction. IMH was associated with more
severe infarction and worse short‐term left ventricular function in
patients with STEMI.

Clinical Perspective

What is New?

This is the
first study to link periprocedural additional glycoprotein IIb/IIIa
inhibitor treatment to higher occurrence of intramyocardial
hemorrhage in patients with reperfused ST‐segment elevation
myocardial infarction.

CXR and HRCT according to the article, which also mentioned that if
clinical conditions warrant, instead of just doing a HRCT, get a CT
PA gram with simultaneous high resolution images of the lung
parenchyma.

What about
bronchoscopy?

This is not considered routine and what I get from the review is that
the diagnostic confidence derived from HRCT and the anticipation of
how the results might change treatment will influence this decision.
Circumstances that might favor doing bronchoscopy include suspected
acute eosinophilic pneumonia (AEP), suspected acute hypersensitivity
pneumonitis, suspected sarcoid and suspected unusual infection.

When should
antibiotics be given?

According to the review, onset or exacerbation of ILD can be
difficult to distinguish from infection, so always at least consider
them. (Given the all too often undifferentiated nature of the
presentation in critically ill patients, I suspect the threshold
would be low). The review did not comment on the specific type of
coverage. However, many such patients are immunosuppressed, have had
frequent hospitalizations, or are critically ill and those factors
would guide antibiotic choices.

Should
corticosteroids be used?

In cases of clinical deterioration or respiratory failure, which is
the case with most patients who require hospitalization, yes. The
etiology is often unknown, and it must be kept in mind that some
etiologies are known to be highly steroid responsive, particularly
AEP and COP. Recommendations also support the use of steroids for
CTD related ILD, acute HP and drug induced ILD. IPF by comparison is
poorly steroid responsive but current guidelines conditionally
recommend their use.

Cautions that would apply include the ever present risk of unusual
infection and the potential for steroids to increase the risk of
renal crisis in patients with systemic sclerosis.

Lung
transplantation is a consideration for certain non responding
patients

Form the article:

In these cases, lung transplantation may be the only remaining
treatment option. This is particularly true for patients presenting
with IPF, and it is 1 of the most common indications for lung
transplantation. Patients with respiratory failure and ILD should be
evaluated early in the hospital course for transplantation or
considered for transfer to a transplant center. General
contraindications to transplant are age older than 70 years,
underweight or elevated BMI (generally higher than 30), malignancy
within the last 2 years (with the exception of cutaneous squamous and
basal cell tumors), untreatable major organ dysfunction other than
the lung, noncurable chronic extrapulmonary infection (chronic active
viral hepatitis B, hepatitis C, human immunodeficiency virus),
significant chest wall deformity, untreatable psychiatric or
psychologic disease, substance addiction within the last 6 months, or
lack of dependable social support.4

Another excellent review, free full text, is here. Though a
couple of years old it is still relevant and has lots of pearls.